CCMS Medicine Winter 2017 - 24

www.CHESTERCMS.org

LYME DISEASE CAN BE A
DIAGNOSTIC CHALLENGE
By Marina Makous, MD, Assistant Professor of Family Medicine at Columbia University Department of Psychiatry. Dr.
Makous completed a 2-year Fellowship at the Department of
Psychiatry/Neuro-Inflammatory Diseases/Lyme Research and
Evaluation Center. She is seeing patients at her office in Exton,
PA. This article is adapted from the upcoming book by Dr. Fallon with Dr. Makous, published by Columbia University Press.

L

yme disease is the most
common tick-borne illness in
the United States and has a high
incidence in Chester County. It is
caused by the spiral-shaped microbe
Borrelia burgdorferi, a spirochete,
that infects humans through the
bite of a "deer tick." After the bite,
the bacteria rapidly spread from the
skin throughout the body, producing
different symptoms at different times.
In some patients, a healthy immune
system may be enough to eradicate
this spirochete. In most others,
antibiotic treatment is needed to
fight the infection.
It usually takes at least 36 hours of tick
attachment for spirochete to be injected
into the human skin. Infection can occur
with attachments of shorter duration if
the tick fed previously. Other tick-borne

infections, such as the Powassan virus, can
be transmitted within minutes of initial
tick attachment.
After entering the skin, the Lyme
spirochete travels via the bloodstream to
various tissues including the brain, joints,
heart, peripheral nerves, muscles, and
connective tissue. In about 70% of cases,
an expanding skin rash develops in the
weeks following the infection. It often
appears as a reddish or purple oval, but as
it spreads, it may look like a target with
a red perimeter and a central clearing. It
is important to note that some patients
never develop or do not notice this rash.
Other symptoms of Lyme disease may
develop quickly or they may take up
to months or even years to develop as
the spirochetes are adept at evading the
human immune response.

24 C H E S T E R C O U N T Y M e d i c i n e | W I N T E R 2 0 1 7

Since symptoms and signs of Lyme
disease can be diverse and blood tests
are not 100% reliable, diagnosis is
often based on the patient's clinical
history, which is then supplemented by
blood test results. It is important for
the clinician to ask for a full medical
history, including any tick bites or
rashes.
In the early 1990s, the Centers
for Disease Control and Prevention
(CDC) delineated a set of criteria for
the diagnosis of Lyme disease to be used
by public health officials to count the
number of new Lyme disease cases each
year. Although it was recognized that the
manifestations of Lyme disease are quite
diverse and not entirely represented by
the CDC "surveillance criteria," these
criteria were narrowly defined on purpose
to ensure with a high degree of certainty
that all patients included had proven
Lyme disease. These criteria rely on the
externally visible signs, such as the typical
erythema migrans rash, arthritis, facial
nerve palsy, or meningitis with abnormal
spinal fluid markers. These criteria are
not very helpful, however, for assisting
the clinician in detecting Lyme disease
when these markers are not present. For
example, in early Lyme disease, about
30% of patients do not recall the rash.
These patients might instead present
with marked fatigue, muscle pains and


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Table of Contents for the Digital Edition of CCMS Medicine Winter 2017

CCMS Medicine Winter 2017 - 1
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